The quality card

The burgeoning area of health services research at Emory is tapping available decks of knowledge to get better health outcomes at lower costs.

By Sylvia Wrobel

“It was like the baseball movie, Moneyball,” says Sweeney. “The economists threw out our preconceived notions and analyzed mountains of our data in whole new ways. They discovered things in mathematical trends that we couldn’t see in any one patient.” Illustration by Don Morris

Traditional medical research develops a new drug, vaccine, treatment, or protocol, then tests whether it is effective.

By contrast, health services research (HSR) looks at the broad picture of health outcomes, delivery, policies, education, and practice. The basic HSR question is, How can we craft real-world strategies that get the right care to the right people (including the most vulnerable) at the right time, and do it without breaking the bank? It combines clinical information with behavioral, cultural, economic, social, and other factors in health care processes and delivery systems. In an era of increasingly stringent cost containment, this emphasis on the highest quality possible within a given amount of resources makes HSR one of the hottest, fastest-growing research areas not only at Emory but also in the nation.

What We Know about Cardiac Screening

Cardiovascular disease (CVD) is the biggest cause of death worldwide, and it’s a sneaky one. For most people, severe atherosclerotic plaque develops before any symptoms appear. For some, the first symptom is the heart attack that kills them. A number of tests are effective in detecting pre-symptomatic heart disease, but routine testing beyond measures of blood pressure and cholesterol is currently not considered medically necessary and therefore not covered by Medicare or other payers.

Opponents of nationwide screening worry that one test would lead to another, then another, creating needless anxiety and early, lifelong patterns of higher resource consumption. Put simply, the costs of screening asymptomatic individuals might well outweigh the benefits. Or not. Little meaningful information has existed on real-world resource consumption patterns and health care costs following CVD screening in people without symptoms. Until now.

Leslee Shaw’s research analyzed data from more than 6,000 middle-aged and elderly men and women of diverse ethnicity from geographic regions across the United States.

Kim Rask realized that if she wanted to understand why she was getting specific results—and how she could improve them—then she had to understand all the cogs in an interlocking set of patients, physicians, structures, processes, and systems.

John Sweeney, Emory’s chief of gastrointestinal surgery, believes that each patient requires a physician’s full, individualized attention—what he calls “looking the patient in the eye.”

It was a question made for Emory medicine professor Leslee Shaw, who co-directs the Emory Clinical Cardiovascular Research Institute. Funded by the National Heart, Lung, and Blood Institute, Shaw’s research analyzed data from more than 6,000 middle-aged and elderly men and women of diverse ethnicity from geographic regions across the United States, who underwent different screening tests for CVD. (Like most HSR researchers, she seeks new information in the combination and re-analysis of pre-existing studies, making HSR a funding bargain.)

First, Shaw looked at the cost and use of specific tests, projecting clinical outcomes and economic implications for screening all adults over 55. The test that provided the most information for the least amount of money was obvious, even if not what might have been expected, says Shaw. Inflammation has been getting much of the research buzz, recently. It accelerates atherosclerotic buildup, and several clinical trials have investigated the clinical benefit of statin drugs to reduce inflammation and thus risk. But as a one-time screening test, inflammation is problematic. Forty percent of adults have elevated inflammation, and levels can vary, temporarily rising, for instance, if one has a cold. Other non-cardiac specific tests, such as carotid artery thickness or peripheral artery blood pressure, also were less than optimal in identifying heart disease.

A simple coronary calcium scan proved to be the most effective in identifying cardiac risk in populations for the least amount of money. The scans look for calcifications (specks of calcium) in coronary artery walls, providing an early sign of plaque buildup and increased risk for heart disease over the next two to 10 years. The one-time, 10-minute test is relatively inexpensive, and it is noninvasive, requires no contrast dyes, and produces no more—and often less—radiation than annual environmental exposure.

Shaw’s next action step is to present her findings to the U.S. Preventive Services Task Force, which sets the rules for what screening tests Medicare and other payers must cover.

Lessons in Economics

Kim Rask trained as an economist, first at her father’s knee, then in college. As a medical student, she thought she’d put that expertise behind her. However, when she began practicing medicine, she saw economics everywhere—in barriers to access, decisions patients made about resource allocation, and how care was delivered, covered, and incentivized. She quickly realized that if she wanted to understand why she was getting specific results—and how she could improve them—then she had to understand all the cogs in an interlocking set of patients, physicians, structures, processes, and systems. She returned to school for a doctorate in economics.

At Emory, Rask leads the Rollins School of Public Health’s Center for Health Outcomes and Quality. It tackles problems that extend across many areas, bringing together diverse experts, many of whom Rask has recruited from across campus and beyond.

For Rask, “HSR is largely about improving the quality of health care by doing what we already know works. I spend a lot of time telling leaders what we know that can help them within the constraints of their world.”

For example, she currently advises the Alliance for a Healthier Generation, established by the American Heart Association and the William J. Clinton Foundation to reduce the nationwide prevalence of childhood obesity. An Alliance program offers obese children four sessions of physician-designed, insurance-covered nutrition counseling. Claims data suggested too few families took advantage of the service, and Rask’s team of multidisciplinary HSR researchers examined the interlocking parts of the process to understand why. They discovered that although the counseling sessions were good, changes were needed in how sessions were promoted, how families enrolled and were pre-certified, the level of co-pays, and the training needed by staff responsible for coding the sessions for insurance purposes. After these changes were implemented, the program reported markedly improved outcomes.

On another front, Rask is working with Benjamin Druss, Rosalynn Carter Chair of Mental Health, to determine if having a mini-primary care clinic in a mental health facility will help patients get better medical care. They hope the approach can impact the dire statistic that people with severe mental illness die 25 years younger on average than those without, largely because of co-existing medical illness.

Culling Best Practices to Reduce Hospital Readmissions

John Sweeney, Emory’s chief of gastrointestinal surgery, believes that each patient requires a physician’s full, individualized attention—what he calls “looking the patient in the eye.”

Patients love his approach. But when surgery’s clinical quality and patient safety program wanted to understand why some surgery patients were readmitted within 30 days of discharge, Sweeney chose a research partner who never lays eyes on a patient: James Cox, Georgia Research Alliance Eminent Scholar and director of the Experimental Economics Center of the Andrew Young School of Policy Studies at Georgia State.

Unplanned hospital readmissions are a big problem in health care, and not just for the patient. Although percentages differ, depending on conditions and hospitals, roughly six of every 100 patients discharged from hospitals nationwide find themselves back in the hospital within 30 days. Readmission for Medicare patients alone costs more than $17 billion annually. Keeping patients in the hospital longer lowers risk of complications leading to readmission, but unnecessarily prolonged stays lower quality of care and precipitate higher costs.

Sweeney and his surgeons initially approached the problem by focusing attention on individual patients (What went wrong?) and on which operations most often required readmission (those for pancreas, colon, and liver). Then, encouraged by Chris Larsen—Whitehead Professor and Chair of Surgery, who himself is deeply involved in HSR to understand and improve outcomes for post-transplantation patients—Sweeney met Cox, who went straight for the numbers. He and his team of experimental economists analyzed hundreds of thousands of observations on more than 3,000 Emory surgery patients. The team of economists delved through vital signs, laboratory values, number and type of X-rays ordered, and other data recorded several times a day throughout each hospital stay. They tracked underlying medical problems. They matched zip codes to census data to come up with median income and the number of people per household in the census tract in which the patient lived.

“It was like the baseball movie, Moneyball,” says Sweeney. “The economists threw out our preconceived notions and analyzed mountains of our data in whole new ways. They discovered things in mathematical trends that we couldn’t see in any one patient.”

For example, one of the traditional decisions for discharge depends on a normal white blood count the morning of release from the hospital. But the data showed that measuring how long the white blood count had been normal was important. The same with how long the patient had been following a normal diet.

And like all HSR research, the analysis went past clinical factors to look at behavioral, cultural, and social ones, such as whether patients had strong social support. Those who lived in census tracts with more people in each house were less likely to be readmitted.

As a profile emerged for risk associated with complications and unplanned readmissions, Sweeney and Cox developed a software tool that recommends whether an individual should be discharged or stay in hospital. Now in the process of being patented, the tool will be tried next year in simulated situations with medical students, residents, and attending physicians at Emory before a pilot project begins with patients.

It’s not meant to replace the surgeon’s expertise, says Sweeney, but rather to provide more evidence to help surgeons make decisions quickly and accurately.

Emory GI surgeons have been following the research closely, and awareness is already having a positive effect. Reporting on a sample of 2,400 patients, Sweeney estimates that 70 to 100 complications were prevented, based on the number anticipated in such a patient group by the American College of Surgeons National Surgery Quality Improvement Program. With complication costs running anywhere from $5,000 to $50,000 per patient, this represents a savings of $1.5 to $2 million for patients, the hospital, and payers (twice that if the findings are extrapolated to all surgery patients last year).

“HSR is improving our patients’ lives,” says Sweeney, “and it’s changing our culture, including how our medical students and residents are learning to think about the care they provide and the system in which they provide it.”

Emory is a natural leader of health services research (HSR), says David Stephens, Woodruff Health Sciences Center (WHSC) VP of Research, for several reasons. One, it’s connected to a large and integrated health care system, a broad base of investigators, education programs, and strong health-related partnerships. Two, diverse patient populations allow Emory researchers to study cultural differences and equity issues that are important to this emerging research area. And three, a growing culture of collaboration across campus and beyond local and state borders is building momentum to understand this data.

Current ongoing HSR inquiries cover a wide-ranging territory from economics to delivery to outcomes. They include studies to understand the costs associated with obesity or smoking during pregnancy, examine disparities in health care delivery in hospitals, evaluate the impact of training programs on quality in health care, identify predictors of diabetes, and develop personalized plans for optimal health.

An initiative that attempts to capture a full picture of HSR not only at Emory but also in the region is the Emory/Georgia Tech Healthcare Innovation Program (HIP). Led by Fred Sanfilippo, former WHSC CEO, HIP is a virtual network that is connecting all of the information, resources, and people involved in health services research and education throughout the region to help facilitate health care innovation. Funded by the Woodruff Fund in the WHSC and the Atlanta Clinical & Translational Science Institute, HIP has an external advisory board of national experts—recognizing the growing importance of HSR to national health care challenges.

In December 2011, the program announced its first two seed grants for multi-investigator and multidisciplinary teams that are using innovative approaches to address issues of health care quality, costs, and access to care. One grant will support the development of a virtual reality simulator to supplement surgical training for medical residents, and the other supports studies of a device to diagnose pneumonia from coughed droplets. The program also is rolling out a quarterly health care innovation symposia series in 2012, and the first topic is no small one—fixing U.S. health care. For more information, see hip.emory.edu.